coordinated perinatal systems of care - indiana · 2019-12-10 · strengthening perinatal systems...

Coordinated Perinatal Systems of Care

Recommendations to the Indiana Perinatal Quality Improvement Collaborative (IPQIC)

Governing Council

Endorsed by the Governing Council on May 21, 2014

2014

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TableofContents

LiteratureReview..................................................................................................................................................................................3

Definition...................................................................................................................................................................................................4

RolesandResponsibilities.................................................................................................................................................................5

1.PerinatalConferences:...............................................................................................................................................................5

2.TrainingforAffiliateHospitals:..............................................................................................................................................5

3.QualityAssurance.......................................................................................................................................................................6

4.SupportServicesthatwillbeprovidedbytheCenterstoaffiliatehospitals:....................................................7

5.CoordinationofMaternal‐FetalandNeonatalBackTransportstoAffiliateHospitals................................7

6.Transitiontopost‐partumandinterconceptioncare..................................................................................................8

7.NICUTransitiontoHome&Follow‐upProgram............................................................................................................8

8.Develop&ImplementAgreements(MOU).......................................................................................................................8

AppendixA:PerinatalCentersQualityMeasures.................................................................................................................12

AppendixB:TransportQualityMeasures................................................................................................................................19

AppendixC:TransportAlgorithms.............................................................................................................................................23

AppendixD:SharedPatientResponsibilities.........................................................................................................................26

AppendixE:AnnotatedBibliography.........................................................................................................................................29

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COORDINATEDPERINATALSYSTEMSOFCARE

TheIndianaPerinatalQualityImprovementCollaborative(IPQIC)SystemDevelopmentCommitteeis

recommendingthattheGoverningCouncilendorsetherecommendationthatCoordinatedPerinatal

SystemsofCarebeestablishedthatwillpromotehighqualityservicedeliverysystemsandrisk

appropriatehealthcarebefore,duringandafterpregnancyforallwomenofchildbearingage.Thereis

significantevidencethatastatewidecoordinatedperinatalsystemofcarewillimproveinfantmortality

andmorbidityandreducethecostofcareforhighrisknewborns.TheCoordinatedSystemswillalso

promoteandensurethatallhospitals,regardlessoflevel,haveanimportantroletoplayinassuringthat

allbabiesborninIndianahavethebeststartinlife.

LiteratureReview

In1976,alandmarkdocument,TowardImprovingtheOutcomeofPregnancy,Recommendationsforthe

RegionalDevelopmentofMaternalandPerinatalHealthServices(TIOPI),wasreleasedbyanadhoc

CommitteeonPerinatalHealth.1Constructedfromagrowingbodyofevidencesuggestingthatratesof

perinatalmortalitycanbegreatlyreducedifpatientsareidentifiedearlyandgivenappropriatecare,2the

MarchofDimes,alongwithmemberrepresentationthatincludedtheAmericanAcademyofFamily

Physicians,AmericanAcademyofPediatrics,AmericanCollege(nowCongress)ofObstetriciansand

Gynecologists,andtheAmericanMedicalAssociation,proposedasystemofregionalizedcarebasedon

designatedlevelsofcareateachfacilitywhichincludedaninter‐hospitaltransportsystem,andthat

wouldhaveformaloversightbyaneutralentity.3Theimpactofthisdocumentonperinatalhealthcare

deliveryintheUnitedStateswasbroadandimmediateasthisidealsystemofcarebegantobe

implementedinvaryingdegreesbystatesoverthenextseveraldecades.Furtherresearchlookedatthe

economicimpactandtheoverallcosteffectivenessofimplementinggeographicalsystemsofperinatal

care.4

Severalstudyreviewssupportregionalizationasaconduitforimprovingperinatalmortalityand

morbidity.5‐11Thedatasuggestthatstateswithformalizedregionalprogramshavelowerinfant

mortalityrates,betteroutcomesandresourceutilization,andlowercostexpendituresthanstates

withoutsuchregionalization.12Improvingperinatalmortalityandmorbidityratesistheultimategoal,

yetshort‐termmeasuresofqualityassurancecanalsoinclude:accessequality,appropriatecapacityand

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staffing,areductionininappropriatetransfers,andnetworksthathaverobustlocalcommunicationand

collaboration.13

Strengtheningperinatalsystemsofcareinstatesthathaveunfinishedbusinessofhighinfantmortalityis

effective,especiallyamongthemostpreterminfants.7“Althoughtheyrepresentlessthan2%ofUS

births,55%ofinfantdeathsoccuramongverylowbirthweightinfants.”5AmajorintentoftheMarchof

DimesTIOPIwastoidentifyandtransferhigh‐riskpregnanciesinutero,asneonataltransferismuch

riskier.14HealthyPeople2020goalsrecognizeincreasingtheproportionofverylowbirthweightinfants

borninLevelIIIhospitalsasanationalprioritymeasure,targetedto83.7%.15Indiana2011(latestdata

available)percentagesarelowerthannationalprioritygoalsaswellasoverallUSpercentagesatjust

69%.16

Theimpactofappropriatecareisnotlimitedtothesmallestandyoungestprematureinfants.Areviewof

17studiesrelatedtoperinataloutcomesandregionalizedperinatalsystemsfoundthat,inadditiontoa

declineinneonatalmortalityoverall,verylowbirthweightinfantsweremorelikelytobebornin

appropriateLevelIIIfacilitieswithaformalsystemofperinatalregionalization,whichimprovedthe

outcomeforinfantsadmittedtoLevelIfacilities.4Andfinally,inadditiontoimprovingoutcomesforhigh

riskpregnanciesandbirths,regionalizationstratifiescarebylevelinordertomatchperinatalpatientsby

riskandensurescost‐effectiveutilizationofavailableresources.17

BenjaminDisraeli,notedstatesman,oncesaid,“Thehealthofthepeopleisreallythefoundationupon

whichalltheirhappinessandalltheirpowersasastatedepend.”Theformaldevelopmentof

regionalizedperinatalcarewillnotbeaneasytask.Inallinstancesofimplementation,theperseverance

ofvisionaryindividuals,hospitals,supportorganizations,andgovernmentalentitiesworkingtogether

withthepurposeofimprovingperinatalhealthmustbetheoverarchingdrivertoachievesuccess.18

Definition

ThePerinatalCentermustmeettheACOGandAAPguidelinesforaLevelIIIObstetric(OB)Unitanda

LevelIIIorIVNeonatalUnit.ItsaffiliatehospitalswillmeettheguidelinesforLevelIorIIOBandfor

LevelI,IIandIIINeonatal.TheLevelIorIIOBandLevelI,IIandIIIneonatalunitsmaybeaffiliatedwith

morethanonPerinatalCenter.InadditionallPerinatalCenterswillberequiredtoparticipateinthe

VermontOxfordNetwork(VON)andtheIndianaVermontOxfordNetwork(IVON).

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RolesandResponsibilities

ThePerinatalCentershavethefollowingresponsibilitieswiththeiraffiliatehospitals'deliveryunits:

1.PerinatalConferences:

EachPerinatalSystemisresponsibleforparticipatinginaStatewidePerinatalConference,

sponsoredbytheIndianaStateDepartmentofHealth,thatbringstogetherallperinatalsystems

tosharetimelyregionalmortalityandmorbiditystatistics,identifybestpracticesand/or

challengeswithtimeforsolutiondiscussion,evaluateregionalFIMRand/orMaternalMortality

data,evaluategeneraltransportdata,andincorporateISDHupdates.

EachPerinatalSystemanditsaffiliatesmustholdanannualmeetingthatwouldincludetimely

localsystemmortalityandmorbiditystatistics,alsoidentifybestpracticesand/orchallenges

withtimeforsolutiondiscussion,evaluatesystemFIMRand/orMaternalMortalitydata,

evaluategeneraltransportdata,andincorporateISDHupdates.Perinatalsystemsthatshare

commongeographyareencouragedtojointlyconducttheirmeetings.

2.TrainingforAffiliateHospitals:

ThePerinatalCenterwillprovidetrainingfortheiraffiliatehospitalsrelatedtobothobstetricand

neonataltopics:

Obstetric

Topicsmayincludebutarenotlimitedto:

o Basicfetalheartratemonitoring(mandatory)/advancedfetalheartmonitoring;

o HighriskOB(e.g.,identificationofhighriskpatients,indicationsfortransfer,

developmentofprotocolswithneonatology);

o Conferences/Trainingsdevelopedtoaddresslocallearningneeds;

o Nursingexchangeprogram(e.g.,shadowing,orientation,nursingin‐services);

o Perinatalhospiceandbereavementtraining;

o Trainingfortransportteampersonnel;

o Teamtraining(communicationandpatientsafetyissues);and

o Conferences/Trainingsdevelopedtoaddresslocallearningneeds.

Neonatal

Topicsmayincludebutarenotlimitedto:

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o STABLE(Postresuscitation/pre‐transportStabilizationcareofsickinfants)S.T.A.B.L.E.

standsforthe6assessmentparameterscoveredintheprogram:Sugar,Temperature,

Airway,Bloodpressure,Labwork,andEmotionalsupportforthefamily;

o NRP(NeonatalResuscitationProgram);

o Nursing/Respiratorytherapy(RT)exchangeprogram(e.g.,shadowing,orientation,

nursingin‐services);

o Perinatalhospiceandbereavement;

o Trainingoftransportteampersonnel;

o Teamtraining(communicationandpatientsafetyissues);and

o Conferences/Trainingsdevelopedtoaddresslocallearningneeds.

3.QualityAssurance

ThePerinatalCenterwillberesponsiblefortheimplementationofthefollowingobstetricandneonatal

qualityassurancemetricsinaffiliatehospitalsasappropriatetoeachhospital'slevelofcare.Thesedata

willbereportedtothestateandwillbeusedtoidentifybestpracticesthatsupportoptimalperinatal

outcomes.ThedefinitionofeachmetriciscontainedinAppendixA.

ObstetricMeasures:

o MaternalDeath;

o SentinelEvents;

o Maternaltransports;

o RupturedUterus;

o 5minuteApgar<4;

o ElectiveDeliverywithoutmedicalindicationat<390/7weeksgestation;

o Deliveryat>416/7weeksgestation;and

o FetalDemiseat>200/7weeks;

o Deathsinthedeliveryroom;

o AntenatalSteroidAdministration;and

o Anyadditionaleventidentifiedbyhospitalstaff.

NeonatalMeasures:

o Allneonataltransports;

o SentinelEvents;

o InfantMortality>12hours;

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o InfantMortality<12hours

o AnyrespiratorysupportforVLBWbabiesat36weeks;

o Lateonsetsepsis/bacteremia;

o Hypothermiaonadmission;

o Mother'smilkatdischarge;and

o Anyadditionaleventidentifiedbyhospitalstaff.

4.SupportServicesthatwillbeprovidedbytheCenterstoaffiliatehospitals:

Obstetric:

o MaternalFetalMedicineconsults24/7(phone/telemedicine);

o MaternalFetalTransports24/7;

o MaternalFetalMedicineoutpatientservices;and

o Reliableandcomprehensivecommunicationsystemforinitiatingtransportthatcanbe

readilyaccessed(i.e.,onequickphonecalltoonenumbertoinitiatetransport).

Neonatal:

o Neonatalconsults24/7(phone/telemedicine);

o NeonatalTransports24/7;

o Reliableandcomprehensivecommunicationsystemforinitiatingtransportthatcanbe

readilyaccessed(i.e.,onequickcalltoonenumbertoinitiatetransport);and

o ImplementationofDevelopmentalFollowupProgram.

5.CoordinationofMaternal‐FetalandNeonatalBackTransportstoAffiliateHospitals

ThePerinatalCenterandaffiliatehospitalphysicianswilldiscusspatient(s)tobetransferredinorderto

assurethatpatientisstablefortransferandthereceivinghospitaliscapableofcontinuingcare.Theplan

ofcaremustbedeterminedjointly.PerinatalCenterspecialists(Maternal‐FetalMedicineand

Neonatology)willbeavailableforquestions,consultationandsupportregardingsharedpatients.

Ifasharedpatientisdischargeddirectlyfromperinatalcenter,specialistswilldiscussthepatientwith

theirprimaryphysician(s)todiscussplanofcare,andensurecontinuityofcare

MaternalFetal:Afterdiscussionwiththereferringobstetricprovider,therewillbeawrittenplan

ofcareforfollowuplocallyfortheremainderofthepregnancy.Thiscanbeinthedischarge

summarysenttothelocalprovider.AsampleformisincludedinAppendixB.Theplanofcarewill

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reflectlocallevelsofcarethatcanbeprovidedbythereferringhospitalandprovider(i.e.

Gestationalagebasedcare,etc).

Neonatal:Regionalperinatalcenterswillmakeeveryefforttotransferpatientsbacktoaffiliate

(referring)hospitals(level4to3and2,level3to2)whenappropriateandbymutualagreement

asspecifiedintheMOU.PerinatalCenterswillberesponsibleforROPfollowupifneeded.

Perinatalcenterswillworkwithaffiliatehospitalattimeofdischargeandprovidedevelopmental

followupasneededandassistwithanysubspecialistfollowup

6.Transitiontopost‐partumandinterconceptioncare

Atthetimeofmaternaldischarge,thedischargingOB/MFMwillcommunicatewiththereferringOB/FP

abouttheoutcomeofthepregnancy.Thiscommunicationwouldincludethediagnosis,briefdescription

ofinpatientmanagementandoutcome.TheOB/MFMwillmakerecommendationsforpost‐deliverycare,

inter‐pregnancycareandmanagementstrategiesforthenextpregnancy.Thisinformationwillbeshared

withthepatient.Thisinformationmaybedocumentedona“form”thatthepatientandreferringMDcan

viewandkeep.

7.NICUTransitiontoHome&Follow‐upProgram

EachPerinatalSystemwillberesponsibleforthefollowingactivities:

RetinopathyofPrematurity(ROP)Screening;

ImplementationofaDevelopmentalClinicforhighrisknewborns;and

Assistanceinaccessingpediatricsubspecialtycareasneeded.

8.Develop&ImplementAgreements(MOU)

ThePerinatalCenteranditsaffiliateswillneedtodevelopandimplementindividualagreementsthat

specifytherelationshipandreciprocalresponsibilitiesthateachwillhave.Thisisespeciallyimportant

whenhospitalsaffiliatewithmorethanonePerinatalCenter.Frequencyofvisitsandspecificeducational

supportwillbedeterminedbytheneedsofeachaffiliatehospital,anddescribedintheagreement;

DatasharingagreementsmustbepartofMOU;and

PerinatalCenterswillprovidetrainingandsupport,butultimateresponsibilityforpatientcare

andoutcomeswillremainwithindividualhospitals

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TheMOUwillneedtoaddressissuesfromboththeperspectiveofthePerinatalCenterandtheAffiliateHospitals.

ThefollowingarecomponentsthatmustbediscussedintheMOU:

1) RegionalPerinatalCenters:

a) Coordinationofregionalmeetings;

b) Training(asspecifiedinMOU)foraffiliatehospitals;

c) Annualvisittoaffiliatehospitalstoevaluateoutcomesandassistwithqualityassurance;

d) Supportservices(asspecifiedinMOU)toaffiliatehospitalsincludingtransports;and

e) Supportforthetransitionofpatientsfromspecialists(MFM/neonatologists)toprimary

physicians.

2) AffiliateHospitals:

a) Compliancewithstatestandardsrequirements;

b) Collectionofqualityassurancedata;

c) Attendanceandparticipationinregionalmeetings;

d) Collaborationwithperinatalcentersandprovisionofdataduringannualvisittoevaluate

outcomes;and

e) Collaborationwithperinatalcenterrelatedtotransitionhomeandbacktransportsofshared

patients.

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References

1. CommitteeonPerinatalHealth.(1976).Towardimprovingtheoutcomesofpregnancy,

recommendationsfortheregionaldevelopmentofmaternalandperinatalhealthservices.White

Plains,NY:MarchofDimesNationalFoundation.

2. TheAmericanCollegeofObstetricsandGynecology.(1975).Towardimprovingtheoutcomeof

pregnancy:Recommendationsfortheregionaldevelopmentofperinatalhealthservices.Journalofthe

AmericanCollegeofObstetricsandGynecologists,45(5),375‐384.

3. MarchofDimes.(2011).TowardimprovingtheoutcomeofpregnancyIII.WhitePlains,NY:Marchof

DimesFoundation.

4. Neogi,S.,Malhotra,S.,Zodpey,S.,Mohan,P.(2012).Doesfacility‐basednewborncareimprove

neonataloutcomes?Areviewoftheevidence.IndianPediatrics,49,651‐658.

5. Lasswell,S.,Barfield,W.,Rochat,R.,Blackmon,L.(2010).Perinatalregionalizationforverylow‐birth‐

weightandverypreterminfants,ameta‐analysis.TheJournaloftheAmericanMedicalAssociation,

304(9),992‐1000.

6. Strobino,D.,Grason,H.,Koontz,A.,Silver,G.(2000).Reexaminingtheorganizationofperinatalservice

systems:Apreliminaryreport.Women’sandChildren’sPolicyCenter,Baltimore,MD.

7. Lorch,S.,Baiocchi,M.,Ahlberg,C.,Small,D.(2012).Thedifferentialimpactofdeliveryhospitalon

outcomesofprematureinfants.Pediatrics,130,270‐278.

8. Bode,M.,O’Shea,M.,Metzguer,K.,Stiles,A.(2001).Perinatalregionalizationandneonatalmortalityin

NorthCarolina,1968‐1994.AmericanJournalofObstetricsandGynecology,184(6),1302‐1307.

9. WrightJ.,Herzog,J.,ShahM.,BonannoC.,LewinS.,ClearyK.,SimpsonL.,GaddipatiS.,SunX.,D’Alton

M.,Devine,P.(2010).Regionalizationofcareforobstetrichemorrhageanditseffectonmaternal

mortality.Obstetrics&Gynecology,116(6),1194‐1200

10. BronsteinJ.,CapiloutoE.,CarloW.,Haywood,J.,Goldenberg,R.(1995).Accesstoneonatalintensive

careforlow‐birthweightinfants:theroleofmaternalcharacteristics.AmericanJournalofPublic

Health,85(3),357‐361.

11. Haberland,C.,Phibbs,C.,Baker,L.(2006).Effectofopeningmidlevelneonatalintensivecareunitson

thelocationoflowbirthweightbirthsinCalifornia.Pediatrics,118,e1667‐e1679.

12. Staebler,S.(2011).Regionalizedsystemsofperinatalcare:healthpolicyconsiderations.Advancesin

NeonatalCare,11(1),37‐42.

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13. Marlow,N.,Gill,B.(2006).Establishingneonatalnetworks:

14. Hein,H.RegionalizedperinatalcareinNorthAmerica.(2004).SeminarsinNeonatology9,111‐116.

15. UnitedStatesDepartmentofHealthandHumanServices.(2013).HealthyPeople20/20:Maternal,

Infant,andChildHealth.Retrievedfrom:

http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=26

16. IndianaStateDepartmentofHealth.(2013).LevelsofCareOutcomes[PowerPointSlides].

17. CommitteeonFetusandtheNewborn.(2012).Levelsofneonatalcare.Pediatrics,130,587‐597.

18. Yu,V.,Dunn,P.(2004).Developmentofregionalizedperinatalcare.SeminarsinNeonatology,9,89‐97.

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AppendixA:PerinatalCentersQualityMeasures

PerinatalCentersQualityMeasures

Page1of6

NeonatalMeasuresReportbyEachLevelofCare

Metric Definition Numerator Denominator LevelI1

LevelII

LevelIII

LevelIV

N1.Allneonatalinterfacilitytransports

QualityMeasuresidentifiedinthe IndianaPerinatalTransportStandards

E E E E

N2.Sentinelevents

“Asentineleventisanunexpectedoccurrenceinvolvingdeathorseriousphysicalorpsychologicalinjury,ortheriskthereof.Seriousinjuryspecificallyincludeslossoflimborfunction.Thephrase"ortheriskthereof"includesanyprocessvariationforwhicharecurrencewouldcarryasignificantchanceofaseriousadverseoutcome.”Reference:http://www.jointcommission.org/sentinel_event.aspx

#ofSentinelEvents

E E E E

N3.Mortality>12hours

Infantswhodidnotdieinthedeliveryroomandwhosurvivedmorethan12hoursafterbirth.Ifyourpatientistransferredtoahigherlevelnursery,anddiesthere,themortalityisassignedtoyourhospital

Reference:VermontOxfordNetwork

#ofdeaths Alladmissions E E E E

N4

Mortality<12hours

Babiesthatdieinthefirst12hoursafterdeliveryandwhodidnotdieinthedeliveryroom

#ofdeaths Allbirths> 22weeks

E E E E

1LevelIisthewellnewbornnursery.IfahospitalhasaLevelIandanotherLevelNICU,datamustbereportedseparately.


Page2of6



LevelII

LevelIII

LevelIV

N5.Anyrespiratorysupportat36weeks

VLBWinfantseithercontinuouslyorintermittentlyreceivingsupplementaloxygenat36weeksgestationalageordischargedtohomebefore36weeksonoxygen.

Reference:BabyMonitor/VermontOxford

#VLBWinfantswhomeetVermontOxfordcriteriafor“ChronicLungDisease”and/or“OxygenatDischarge”

AllVLBWsurvivorstoage36weeksGAordischarge

NA E E E

N6.LateOnsetSepsis/Bacteremia

Apositivebloodculture,obtainedinthepresenceofcompatibleclinicalsignsofsepticemia,occurringafter72hours,andtreatedwithantibioticsfor≥5days.Includesculturepositiveepisodesinwhichtheinfantdiesbeforeanintendedtherapyoffiveormoredaysiscompleted.

VermontOxford

AllinfantsdiagnosedwithlateonsetsepsisasperVONcriteria

Alladmissions NA E E E

N7.Hypothermiaonadmission

Axillarytemperaturelessthan36degreescentigradewithin60minutesafterbirth.

Reference:Bhatt,White,etal.,JPerinatal2007;27:S45‐47,

Reference:BabyMonitor

AllinfantswithTemperature<36.0°C

Alladmissionswithtemperaturemeasurementinthefirsthour

E E E E


Page3of6



LevelII

LevelIII

LevelIV

N8(a).Babiesweighing<1500gmsatbirthdischargedonownmother’smilk

Babiesweighing<1500gramsatbirthdischargedonanyamountofownmother’smilk

#ofbabiesweighing<1500gramsatbirthdischargedonanymother’smilk

#ofbabiesweighing<1500gramsatbirthdischargedtohome

NA

E

E

E

N8(b)AllotherbabieswithownMother'smilkatdischarge

Babiesweighing>1500gramsatbirthwhowereexclusivelybreastfedorwhowerefedformulainadditiontoownmother’smilkatdischarge.

#ofbabiesweighing>1500gramswhowerefedonlyownmother'smilkand#ofbabieswhowerefedownmother'smilkandformula.

#ofbabieswhowereeligibleforbreastfeeding.Babieswhowerestillborn,born,pre‐termortwinsarenotincluded.

E E E E

N9.Anyadditionaleventidentifiedbyhospitalstaff

E E E E


Page4of6

ObstetricMeasuresMetric Definition Numerator Denominator LevelI LevelII LevelIIIOB1.Maternaldeath

Forreportingpurposes,apregnancy‐relateddeathisdefinedasthedeathofawomanwhilepregnantorwithin1yearofpregnancytermination—regardlessofthedurationorsiteofthepregnancy—fromanycauserelatedtooraggravatedbythepregnancyoritsmanagement,butnotfromaccidentalorincidentalcauses.Reference:http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

#ofpatientswhomeetthecriteria

Allpatientswhodeliver

E E E

OB2.Sentinelevent

Asentineleventisanunexpectedoccurrenceinvolvingdeathorseriousphysicalorpsychologicalinjury,ortheriskthereof.Seriousinjuryspecificallyincludeslossoflimborfunction.Thephrase,‘ortheriskthereof"includesanyprocessvariationforwhicharecurrencewouldcarryasignificantchanceofaseriousadverseoutcome.Reference:http://www.jointcommission.org/sentinel_event.aspx

#ofSentinelEvents

E E E

OB3.Maternalinterfacilitytransports

QualityMeasuresidentifiedintheIndianaPerinatalTransportStandards

E E E

OB4.Ruptureduterus

Uterinerupturetypicallyisclassifiedaseithercomplete(alllayersoftheuterinewallseparated)orincomplete(uterinemuscleseparatedbutvisceral

#ofwomenwhomeetthecriteria

Alldeliveries E E E


Page5of6

ObstetricMeasuresMetric Definition Numerator Denominator LevelI LevelII LevelIII

peritoneumisintact).Incompleteruptureisalsocommonlyreferredtoasuterinedehiscence.Reference:WilliamsObstetrics

OB5.5minuteAPGAR<4

BabieswithanApgar<4at5minutes

Alldeliveries E E E

OB6.Electivedeliverywithoutmedicalindication<390/7weeksgestation

Electivedeliverieswithoutmedicalindicationsthatareperformedbefore390/7weeks.WebLinktoISDH/IPQICGuidelinestoReduceEarlyElectiveDeliveries,January2014

Alldeliverieswithoutmedicalindicationlessthan390/7weeks

Alldeliveriesunder390/7weeks

E E E

OB7.Deliveryat>416/7weeks

#ofdeliveriesthatmeetthecriteriaof>416/7weeks

Alldeliveries E E E

OB8.Fetaldemiseat>200/7weeks

Fetaldeath”meansdeathpriortothecompleteexpulsionorextractionfromitsmotherofaproductofhumanconception,irrespectiveofthedurationofpregnancy,andwhichisnotinducedterminationofpregnancy.Thedeathisindicatedbythefactthataftersuchexpulsionorextraction,thefetusdoesnotbreatheorshowanyotherevidenceoflife,suchasbeatingoftheheart,pulsationoftheumbilicalcord,ordefinitemovementofvoluntarymuscles.Heartbeatsaretobedistinguishedfromtransientcardiaccontractions;respirationsare

Numberoffetaldeaths

Alldeliveries E E E


Page6of6

ObstetricMeasuresMetric Definition Numerator Denominator LevelI LevelII LevelIII

tobedistinguishedfromfleetingrespiratoryeffortsorgasps.”Reference:http://www.cdc.gov/nchs/data/misc/itop97.pdfACOGPracticeBulletin#102(March2009)

OB9.Deathsinthedeliveryroom

Deathsthatoccurafterbirthandbeforeadmissiontothenursery.

Alldeathsthatmeetthedefinition

Alldeliveries E E E

OB10.AntenatalSteroidAdministration

Antenatalcorticosteroidsadministrationtopregnantwomenbetween24weeksofgestationand34weeksofgestationwhoareatriskofpretermdeliverywithin7daysReference:ACOGPracticeBulletin#127,June2012

Womenwhodeliveredbetween24weeksofgestationand34weeksofgestation,whoreceivedatleastonedoseofantenatalcorticosteroid,atleast12hourspriortothedelivery

Allpretermdeliveriesbetween24weeksofgestationand34weeksofgestation

E E E

OB11.Anyadditionaleventidentifiedbyhospitalstaff

E E E

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AppendixB:TransportQualityMeasures

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StandardII:Maternal‐FetalQualityAssurance2.1Inadditiontocomplyingwithallreportsandrecordsrulesin836IAC1‐1‐5,thecertifiedprovideroftheMaternalFetalTransportProgramshalltrackthefollowingbenchmarks:

a. Delivery≤30minutesfromarrivalatreceivinghospital;b. Diversionoftransportduetomaternalandorfetalstatuschangeinroute;c. Incidenceoflossofcommunicationwithmedicalcontrolforanythinglonger

than5minutes;d. Changeintransportasset(groundtoairorviceversa);e. Deliveryinroute;f. Incidenceofsentinelevents;g. Transportcrewmemberinjuryduringtransport;h. Anyreasonfortransportdelay:

i. Accident—MotorVehicleAmbulance,flight;ii. Delayinunscheduledtransportdispatchtimeis>15minutes;iii. Delayinunscheduledtransportenroutetimeis>15minutes;iv. Mechanicalfailureofambulanceoraircraftthatleadstoatransport

delay;v. Equipmentfailure;vi. Weatherorroadrelated(constructions,accidents)issues;vii. Crewmember;

h. Maternalfetalinjuryduringtransport;andi. Maternalandorfetalstatusdeemedunstablefortransportatsendingfacility.

2.2Whenasentineleventoccurs,theperinataltransportteam,medicaldirector,andmedicalcontrolphysicianmusthaveadebrief.Thedebriefmustbeinitiatedwith72hoursandtherootcauseanalysiscompletedwithin5workingdays.2.3Teamsarerequiredtohaveapre‐transportbriefingregardingthepatient(s)conditionpriortoassumingcareofthepatient(s).2.4Eachperinataltransportteamshallhavewritteninternalqualityreviewprocedures/protocols.2.5EachhospitalwithanperinataltransportteamshallimplementaroutinescheduleofQualityImprovementmeetingsandarecordofminutesmaintained.2.6Transportteamsmustconductquarterlyreviewsofthefollowingelementsandmaintaindocumentationofthereviewsincompliancewith836IAC1‐1‐5(c):

a) Transportindication(s);b) Medicaland/ornursinginterventionperformedormaintained;c) Timeofintervention:

a. patientresponsetointerventions;andb. appropriatenessofinterventionperformedoromissionofneeded

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StandardII:Maternal‐FetalQualityAssuranceintervention

d) Patientoutcomeatarrivalofdestination;e) Patient'schangeinconditionduringtransport;f) Timelinessandcoordinationofthetransportfromreceptionofrequesttoliftoff

orambulanceenroutetime;g) ReviewofPre‐transportinspectiondocumentationh) Safetypracticesdocumented;i) Operationalcriteria:

a. numberofcompletedtransports;b. numberofabortedorcanceledflights/transportsduetoweather;c. numberofabortedorcanceledflights/transportsduetomaintenance;d. numberofabortedorcanceledflights/transportsduetopatientcondition

andalternativemodesoftransportation;ande. numberofabortedorcanceledflights/transportsduetounavailable

team.j) Communicationscenterororganizationmustmonitorandtrack:

a. InstrumentFlightRules(IFR)/VisualFlightRules(VFR);b. Weatherattimeofrequestofthereferringandacceptingfacilityand

duringtransportifchangesoccur;c. Transportacceptancetoliftofftimesortheroadtimes;andd. Allabortedandcancelledtransportrequests‐times,reasonsand

dispositionofpatientsasapplicable.

StandardVI:NeonatalQualityAssurance6.1Inadditiontocomplyingwithallreportsandrecordsrulesin836IAC1‐1‐5,theCertifiedProvideroftheNeonatalTransportProgramshalltrackthefollowingbenchmarks:

a) Unplanneddislodgementoftherapeuticdevices;b) Radiographverificationoftrachealtubeplacement;c) Averagemobilizationtimeoftransportteam;d) Firstattempttrachealtubeplacementsuccess:

a. visualizations;b. attemptsatplacement;

e) Rateoftransport‐relatedpatientinjuries;f) Rateofmedicationadministrationerrors;g) RateofCPRperformedduringtransport;h) Incidenceofsentinelevents;i) Unintendedneonatalhypothermiauponarrivaltodestination;

22

StandardVI:NeonatalQualityAssurancej) Transportcrewinjuryduringtransport;andk) Standardizedpatientcarehand‐offperformed(sitespecificprotocolused).

6.2Whenasentineleventoccurs,theneonataltransportteam,medicaldirector,andmedicalcontrolphysicianmusthaveadebriefthatisinitiatedwithin72hoursandtherootcauseanalysiscompletedwithin5workingdays.6.3Teamsarerequiredtohaveapre‐transportbriefingregardingthepatient(s)conditionpriortoassumingcareofthepatient(s).6.4Eachperinataltransportteamshallhavewritteninternalqualityreviewprocedures/protocols.6.5EachhospitalwithaneonataltransportteamshallimplementaroutinescheduleofQualityImprovementmeetingsandarecordofminutesmaintained.6.6TheneonataltransportteamconductsaQuarterlyReviewofthefollowingelementsandmaintaindocumentationofthereviewsincompliancewith836IAC1‐1‐1‐5(c):

A. Reasonfortransport;B. Mechanismofillness;C. Medicalinterventionperformedormaintained;D. Timeofinterventionconsistentlydocumentedfor:

a. patientresponsetointerventions;andb. appropriatenessofinterventionperformedoromissionofneeded

intervention;E. Patientoutcomeatarrivalofdestination;F. Patient'schangeinconditionduringtransport;G. Timelinessandcoordinationofthetransportfromreceptionofrequesttoliftoffor

ambulanceenroutetime;H. Pre‐transportcheckofambulancebyEMTonTransportrecords;I. Operationalcriteriatoinclude,ataminimum,thefollowingqualityindicators:

a. numberofcompletedtransports;b. numberofabortedorcanceledflights/transportsduetoweather;c. numberofabortedorcanceledflights/transportsduetomaintenance;d. numberofabortedorcanceledflights/transportsduetopatientcondition

andalternativemodesoftransport;J. CommunicationsCenteroforganizationmustmonitorandtrack:

e. InstrumentFlightRules(IFR)/VisualFlightRules(VFR)f. weatherattimeofrequestandduringtransportifchangesoccur;andg. allabortedandcanceledtransportrequests‐times,reasonsanddisposition

ofpatientsasapplicable.

23

AppendixC:TransportAlgorithms

Draft Maternal Fetal Transport AlgorithmOctober 2013

> 23 Weeks with Viable Fetus

On Magnesium Sulfate

Active Labor

Other Maternal Co-morbidities

Surgical Candidate

Potential for Maternal and/or Neonatal

complications at delivery

Currently requires continuous Maternal Fetal

Monitoring

Maternal Fetal RN lead Ground or Flight

Transport

Consider Flight for:• Maternal admission to an adult intensive care unit• High risk of delivery before the ground unit would return with patient• Maternal trauma• Ground team unavailable

Patient receiving intermittent Maternal Fetal Monitoring but not

required during transport

Post partum, fetal demise and/or <23 weeks, maternal status stable

Y

Y

Y

Y

Y

N

N

N

N

Y

N

Y

Basic Life Support (BLS) orAdvanced Life Support

(ALS) Transport

Consider private care if mother and fetus are stable and require no immediate

actionY

Post partum, fetal demise and/or <23 weeks,

unstable maternal status

Consider Maternal Fetal ground, Advanced Life

Support (ALS) or air transport depending on

acuity and distance

Y

Draft Neonatal Transport AlgorithmOctober 2013

LEVEL I NURSERY

Infant less than 35 weeks gestation

Requires supplemental oxygen and/or respiratory

support

Failed Cyanotic Congenital Heart Disease

Screen

Possible Sepsis or Chorioamnionits

Other clinical concerns not supported by the

Institution

Continue to Monitor Infant

Prepare infant for transfer to Level III or Level IV

Institution

LEVEL II NURSERY

Infant less than 32 weeks gestation or birth weight

less than 1500 grams

Failed Cyanotic Congenital Heart Disease

Screen without availability of Newborn

Echocardiography

Likely or Need for Prolonged Respiratory

Support (greater than 24 hours)

Y

Y

Y

Y

Y

Y

N

N

N

NOther clinical concerns

not supported by the Institution

Congenital anomaly requiring surgical

intervention


Y

Y

Y

Y

Y

N

N

N

N

LEVEL III NURSERY

Cyanotic Congenital Heart Disease

Severe Pulmonary Hypertension potentially requiring ECMO if iNO is

not available or failing iNO

Pediatric Surgery need not supported by

Institution

Other Medical or Surgical need not supported by

the Institution


Prepare transfer to

Level IV Institution

Y

Y

Y

Y

N

N

N

NN

N

26

AppendixD:SharedPatientResponsibilities

SUMMARYOFRECOMMENDATIONSFORANTEPARTUMCAREAFTERHOSPITALIZATION

PatientName:

GestationalAge:

SendingHospital:

DateofDischarge:

PrimaryPhysician:PhoneNumberforanyQuestions(24/7):ReceivingHospital:PrimaryPhysician:

ContactInformation:

DiagnosisatDischarge:

MedicationsatDischarge:

AntepartumSurveillanceFrequencyRecommendations:

FrequencyofPrenatalVisits:

BPP:_________________________________________

NST:_________________________________________

GrowthUltrasound:________________________

CervicalLength:____________________________

PrimaryOB:____________________________

o NextAppointment:______________

TertiaryCenter:_________________________

o NextAppointment:______________

DeliveryTiming: DeliveryRoute: Cesarean

Vaginal

OperativeVaginal

DeliverySite: LocalHospital

Tertiary(orhigherlevel)center)

AdditionalRecommendations:

SUMMARYOFRECOMMENDATIONSFORNICUPATIENTSATDISCHARGE

PatientName:

Gestationalageatbirth:Gestationalageatdischarge:

Hospital:

DateofDischarge:

DischargePhysician:PhoneNumberforanyQuestions:

Email:

PrimaryPhysician:

ContactInformation:

BW_________%____LT_______HC______%__________DCWT_______%____LT_______HC___________%_____Main(Active)DischargeDiagnoses:

MedicationsatDischarge:

FEEDINGINSTRUCTIONS:

IMMUNIZATIONSGIVEN(ifany):

FOLLOWUPAPPOINTMENTS:

HOMEHEALTHCAREFOLLOWUP:

(nameofagency/frequencyofvisitsordered)

ADDITIONALRECOMMENDATIONS:

29

AppendixE:AnnotatedBibliography

History of Perinatal Regionalization Annotated Bibliography

1. Bode, M. O’Shea, M., Metzguer, K., Stilies, A. (2001). Perinatal regionalization and neonatal

mortality in North Carolina, 1968-1994. American Journal of Obstetric Gynecology,

184(6), 1302-1307.

Bode et al. study the trends of neonatal mortality in a changing health delivery

environment in North Carolina from 1969-1994. Authors analyzed the number of weighing 500-

1500 g, what level of hospital they were born in, and whether there was a correlation in where

they were born and the mortality rates. Authors conclude the likelihood of very low birth weight

neonates being born outside level III hospitals decreased by an average of 24 percent from 1968-

1994 and after 1974 birth in a hospital with level III services was associated with a reduced rate

of mortality.

2. Bridgman Perkins, B. (1993). Rethinking Perinatal Policy: History of Evaluation of Minimum

Volume and Level-of-Care Standards. Journal of Public Health Policy, 14(3), 299-319.

Bridgman Perkins gives the historical origins of perinatal standards in the United States

from the 1930s through the 1970s. The author details the change in opinions beginning in the

1980s as the health care system in the United States became more competitive in nature. The

paper notes that the discrepancy between the research findings and changes in the delivery of

care continues to be problematic from a financial standpoint.

3. Committee on Fetus and the Newborn. (2012). Levels of neonatal care. Pediatrics, 130, 587-

597.

“Levels of neonatal care,” is an updated policy statement that reviews levels of care for

neonates in the United States since the 2004 policy statement by the American Academy of


Pediatrics (AAP). Authors present new data since the 2004 AAP statement which largely

support a well-defined regional system of perinatal care. The statement provides standards for

health outcomes data comparisons, standardized definitions for public health, and standardized

definitions for healthcare providers who provide neonatal care in the United States.

4. Clement, M. (2005). Pernatal Care in Arizona 1950-2002: A Study of the Positive Impact of

Technology, Regionalization and the Arizona Pernatal Trust. Journal of Perinatology, 25,

503-508.

Clement describes the changes in perinatal care in Arizona from 1950-2002 and its

positive impact on neonatal outcomes. The paper measures these outcomes quantitatively by

analyzing birth and death records in 1950 and 2002 in order to report the change in mortality rate

over time. Clement acknowledges a significant reduction in neonatal mortality rates over the

past 50 years which he attributes to both and advancement in technology and health policy

developed to reduce infant mortality and disparities in the state.

5. Hein, H. (2004). Regionalized perinatal care in North America. Seminars in Neonatology, 9,

111-116.

In this paper, Hein details the status of regionalized perinatal health care in North

America using the Iowa regionalization model. He reviews the history and evolution of

regionalization in the 1960s and 1970s and the role of the March of Dimes in setting the first set

of national guidelines for regionalized perinatal systems of care. In conclusion, Hein makes

suggestions for controlling the impact of managed care on regionalization and quality perinatal

care and makes a case for maintaining a regionalized system and prioritizing utilizing outcome

data when making policy decisions.


6. Philip, A. (2005). The evolution of neonatology. Pediatric Research, 58(4), 799-815.

Philip gives a history of the practice of neonatology in the United States beginning with

first meeting of the perinatal section of the American Academy of Pediatrics in 1975. Philip

surveys the important innovations in technology which coincided with the subspecialty practice.

In conclusion, Philip notes that the change and improvement in neonatal care in the United States

as “remarkable” despite the fact that challenges still exist in the field of modern neonatology.

7. The American College of Obstetrics and Gynecology. (1975). Toward improving the outcome

of pregnancy: Recommendations for the regional development of perinatal health

services. Journal of the American College of Obstetrics and Gynecologists, 45(5), 375-

384.

This policy statement, which was published by the American College of Obstetricians

and Gynecologists in 1975, is the first recommendation for a regionalized system of perinatal

care. The document outlines the hospital levels of care and the basic requirements of each level

for optimal care. The document further outlines recommendations for communication,

collaboration, and referral networks that must exist in a functional system. The final

recommendation in this document acknowledges the financial burden to the higher level

designated hospitals and patient number minimums for each level.

8. March of Dimes. (2010). Toward Improving the Outcome of Pregnancy III. [PDF] Retrieved

from: http://www.marchofdimes.com/materials/toward-improving-the-outcome-of-

pregnancy-iii.pdf

Toward Improving the Outcome of Pregnancy III (TIOP III) is a toolkit which intends to

guide practitioners and policy makers in improving the quality, safety, and performance in the


sphere of perinatal care. TIOP III distinguishes itself from the previous TIOPs by focusing on

the application of evidence based practice and acknowledging the importance of a woman’s

health throughout her life-course and its impact on a healthy pregnancy.

9. Staebler, S. (2011). Regionalized Systems of Perinatal Care. Advances in Neonatal Care,

11(1), 37-42.

Staebler presents options for policies on regionalization of perinatal care from a “doing

nothing” (p. 39) approach to a state or federally mandated regionalized system of care. A

“deregulation” (p. 37) of neonatal services occurred in the United States as the number of

neonatologists and NICUs grew beyond geographical need and hospitals began operating under a

more competitive model. The four policy options Staebler presents are no standardization,

organizational/individual health system standardization, incremental changes at the state or

federal levels, and formal regionalization. While the author gives the pros and cons of each

option, she recommends option four, formal regionalization, as it “has the potential to decrease

unnecessary duplication of services…improve morbidity and mortality, decrease costs, and

promote better utilization of limited workforce personnel” (p. 41).

10. Shaffer, E. (2001). State Policies and Regional Neonatal Care: Progress and Challenges 25

Years After TIOP. [PDF] Retrieved from: http://www.equalhealth.info/wp-

content/uploads/Final-NICU-Report.pdf

This study, completed for the March of Dimes, is the results of a survey of state health

departments and of literature on perinatal systems and their operation in the United States. The

study includes current, by state, (as of the writing of the report) terminology for neonatal

intensive care unit (NICU) levels, policy for defining NICU levels of care, and its enforcement,


as well as how the systems have changed or are currently changing. Major finding of the study

include: substantial variation among states on levels of care definitions, little public knowledge

of NICU levels, and disparate opinions exist among facilities and staff on NICU levels.

11. Yu, V. Y.H., Dunn, P. M. (2004). Development of regionalized perinatal care. Seminars in

Neonatology, 9, 89-97.

Yu and Dunn present a brief history of regionalized perinatal care in Canada, the United

Kingdom, Australia, and the United States. The authors conclude that while regionalizing

perinatal care has great benefits in birth outcomes in all countries studied, there is commonality

in problems that arise when attempting to institutionalize a system of care. Additionally, authors

further conclude that while developing and maintaining regionalized perinatal care is a difficult

task, it can be achieved once the multidisciplinary teams and institutions are able to reach a

common vision for the health of the population.

12. Van Mullen, C. Conway, A., Mounts, K., Weber, D., Browning, C. (2004). Regionalization

of perinatal care in Wisconsin: A changing health care environment. Wisconsin Medical

Journal, 103(5), 35-38.

Van Mullen et al. describe changes in perinatal heath delivery structure in Wisconsin and

the results of an increase in NICUs and neonatologists since the 1970s. This paper is a product

of a series of meetings initiated by the Wisconsin Association for Perinatal Care (WAPC) in

order to discuss the changing perinatal health environment and worsening of perinatal outcomes

in the state. The authors conclude that the competitive health marketplace and lack of

coordinated services have “led to the unnecessary duplication of services within a single

community or geographic region, with the potential fragmentation and decreased coordination of


care resulting in potential fragmentation and decreased coordination of care resulting in

increased patient morbidity and mortality, as well as increased cost” (p. 37). The WAPC will

continue to review the status of the state’s regionalization of perinatal care including

implementing designations for standard levels of care and defining perinatal outcomes with a

focus on quality of care.

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